Chronic Pain Syndromes After Lung Cancer Surgery

The life-saving lung cancer surgery that removes malignant tumors can, in some instances, cause debilitating chest pain, breathing discomfort, burning sensations, and pain with movement. Not all people who undergo surgery for non-small cell lung cancer develop this post-operative problem, but it is common with lobectomy and pneumonectomy. Thankfully, the discomfort is typically manageable and should eventually pass.

If you find yourself suffering from chronic pain after lung surgery, you should discuss it with your healthcare provider immediately so you can begin treatments that can help you deal with the pain while ensuring you stay on the road toward remission.

Chronic Pain Syndromes

Pain after lung surgery is associated with an open-chest lung resection, a procedure that involves surgically opening the chest and pulling back the ribs to either remove tissue from one lung or an entire lung. This is usually done in an effort to remove stage 1, stage 2, or stage 3A cancerous tumors, but may also be used to treat tuberculosis, severe COPD, or trauma to the chest.

Depending on what type of lung resection surgery you undergo, you may be at risk of developing either postpneumonectomy syndrome or post-thoracotomy pain syndrome. A 2014 meta-analysis included a total of 2,793 patients and found that the incidence of post-chest surgery pain syndrome at three and six months after thoracotomy was approximately 50% and had not decreased significantly since the 1990s. 

Postpneumonectomy Syndrome

A pneumonectomy is the removal of one entire lung. In rare cases, within a few weeks to as long as several years after surgery, patients who undergo this procedure may develop postpneumonectomy syndrome (PPS).

PPS is a result of the mediastinum (the portion of the chest cavity that contains the heart, glands, portions of the esophagus, and other structures) shifting toward the space left open by the removal of the lung. This causes severe shortness of breath and chest pain. It can be life-threatening.

Children have a greater risk of developing PPS. It's also more frequent following the removal of the left lung versus the right.

Post-Thoracotomy Pain Syndrome

A thoracotomy is any surgery in which your healthcare provider opens the chest to access the heart, the lungs, esophagus, or other thoracic organs.

Post-thoracotomy pain syndrome (PTPS) is specifically associated with lobectomy operations in which healthcare providers remove lung cancer tumors along with one of the five lobes that make up your lungs (your right lung has three lobes; your left lung has two).

Following surgery, you may experience neuropathic pain, which is chronic discomfort that feels like intense burning, stabbing, or itching (also known as dysesthesia).

Your healthcare provider will probably order several tests to diagnose PPS. These can include computed tomography (CT) scans, pulmonary function tests (PFTs), and bronchoscopy.

A CT scan might be used to rule out tumor recurrence, but to confirm a PTPS diagnosis, nerve blockers or anesthetic medications will be administered to test if your pain responds to those therapies.

Symptoms of Post-Lung Surgery Pain

Chronic pain after lung cancer surgery can take a number of different forms. The pain is mild in most cases, though it can still be inconvenient. About 50% of people report that the pain interferes with their daily life.

Chest pain may develop along the incision site, but other uncomfortable and debilitating problems can occur around nearby areas.

These can cause a variety of sensations:

• Nerve damage-related pain: This may include a dull ache, burning, or sharp pain where scar tissue has developed and entrapped nerves.
• Pinched nerve pain: A neuroma, or abnormal growth of nerve tissue, can develop around the surgical area and result in increased sensitivity to stimuli (such as fabric rubbing against the area) or intensified pain (when something like a small tap on your chest feels several times worse than normal).
• Muscle pain: You may have pain in the chest or shoulder, which could be related to the use of chest tubes during thoracic surgery.
• Painful breathing: This is most commonly a problem associated with the removal of a lung; it can result in severe shortness of breath (dyspnea) and painful coughing.

Pain may be present both with activity and at rest, and many people note a worsening of the pain with arm movements.

Causes

The process of opening up the chest and pushing back the rib cage is invasive. Added to that, your healthcare provider needs to remove tissue in the chest, which disrupts the natural placement of the organs and body systems. The post-operative healing process itself can also lead to late-onset pain.

A combination of factors that can contribute to chronic pain include:

• Compression of the intercostal nerves (nerves that run between the ribs)
• Scar tissue that rubs against other parts of the body each time you breath
• Fractured and compressed ribs
• Inflammation of the chest muscles
• Atrophy of chest muscles

Treatment

A number of different treatments are currently used to help manage pain after a lung resection. Your healthcare providers will likely recommend a combination of treatments to combat the pain rather than one treatment alone. This multi-modal approach has been seen to be more successful because it targets multiple sites that can cause pain.

Oral Medications

The oral medications most commonly prescribed for PPS and PTPS are non-steroid anti-inflammatory drugs (NSAIDs) and opioids. These may be used together or alone.

Opiods

Opioids provide relief to patients by blocking pain. While effective, their use must be carefully considered and monitored.

Opiods pose a range of side effects. Minor ones include sleepiness, constipation, and nausea. They may also cause issues that interfere with everyday life, including confusion. More serious side effects may include shallow breathing, slowed heart rate, and loss of consciousness.

Serious complications could be fatal. These should be reported to a healthcare provider immediately.

Two of the most notable downsides to these drugs are:

• Tolerance: These drugs interfere with the sending of signals to the brain. In an effort to overcome this and get pain signals through, your body responds by making these receptors less active. Eventually, this leads to a built-up tolerance to the dose you've used and the need for a stronger dose to achieve the same level of comfort.
• Addiction: The body becomes used to opioids over time and begins to require the drugs in order to function normally.

NSAIDs

NSAIDS are frequently used in place of opioids because they offer several advantages for lung cancer patients suffering from post-surgery pain, including:

• Eliminating or reducing the need for opioids
• Targeting shoulder pain related to surgery
• Reducing inflammation in the chest that may occur after surgery

Silicone Implants

The use of silicone-filled tissue expanders (similar to breast implants) may be used after a pneumonectomy to prevent pain or eliminate discomfort that can develop when organs and other chest tissue shift toward the spaces left open by the removal of a lung.

These tissue expanders have been shown to relieve symptoms when placed in the chest after a patient begins to experience pain.

Nerve Blocks

An intercostal nerve block is an injection of medication into the intercostal nerve region (located under each rib) that has proven to be successful in relieving chest pain related to lung surgery.

Healthcare providers apply a local anesthetic and then inject either steroid medication or an analgesic (pain medication) into the area where you're feeling discomfort. This can bring down inflammation and ease chronic pain.

You may have some relief immediately after receiving the first injection, but it usually takes a few days for the full effects to begin to be felt. You may need to continue to have regular injections several months apart to remain pain-free.

Coping

For previous generations, a poor prognosis for lung cancer meant that few people who were treated for the disease lived long enough to worry about complications such as chronic postoperative pain.

Today, if there's any silver lining to experiencing such pain it is that it is an indication that treatment advances have made it possible to live a longer life with the disease—long enough for this complication to occur.

Focus on the fact that this is good news, and that as cancer treatments continue to advance, there will be better options to manage your pain. This perspective is part of assuming a positive, hopeful attitude that will help you heal and enjoy life every day.

Also consider meeting with a pain management specialist who can talk you through all your treatment options, both pharmaceutical and non-pharmaceutical, so you feel confident that you're doing all you can to ease your symptoms.

You may also want to look into alternative cancer treatments such as massage therapy and acupuncture, which can help with pain as well as the physical and emotional aftermath of cancer treatment.

A Word From Verywell

With new, less-invasive procedures that allow surgeons to remove cancer without fully opening up the chest cavity (such as video-assisted thoracoscopic surgery), the incidence of PPS and PTPS syndrome will hopefully decrease.